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Individual

AMBYR ROSE STORES

Active
Sole proprietor
No

Provider details

NPI number
Gender
F
Credential
MSW, LCSW, QMHP

Contact information

Practice address
1599 OAK ST, EUGENE, OR 97401-4008
(541) 255-1411
(541) 255-1412
Mailing address
1430 WILLAMETTE ST # 140, EUGENE, OR 97401-4049
(541) 255-1411
(541) 255-1412

Taxonomy

Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
A4910
OR
1041C0700X
Clinical Social Worker
Primary
L10359
OR

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
1730545211
OR
Enumeration date
01/13/2016
Last updated
01/10/2022
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